ANNEXURE X

UTI MUTUAL FUND/SPECIFIED UNDERTAKING OF UTI
LETTER TO BE COMPLETED AND SIGNED BY SURETY FOR ISSUE OF DUPLICATE
UNIT CERTIFICATE OF FACE VALUE OF RS.50,000/- AND ABOVE/S ETTLEMENT
OF CLAIM TO UNITS OF DECEASED UNITHOLDERS

From To
______________________________
(Name) UTI Mutual Fund/Specified Undertaking of UTI
______________________________ _____________________________________
(Address) _____________________________________
______________________________ _____________________________________
______________________________ _____________________________________
______________________________ Date _______________________________
Dear Sir,
I, the undersigned, Shri / Smt _______________________________ beg to inform you that I am prepared to execute an
Indemnity Bond in favour of the UTI MF/SUUTI to enable it to se ttle the claim* without insisting on legal evidence of title in
favour of _______________________________ issue a duplicate unit certificate for unit certificate reported lost in respect of
_______________________________
Occupation or Designation of Declarant
_______________________________
Present Address
Signature of Witness Name of Declarant
__________________________ _______________________________
Address of Witness Name of Declarant’s Father
Witness ____________________________ _____________________________
NAME Signature of the Declarant
__________________________ __________________________
(d) Any other assets _____________Value____
(5) Is the property free from encumbrance? (5) ____________________________________
I do hereby solemnly assure the UTIMF/SUUTI that I have thoroughly understood and correctly answered the above
Answer
If so, state your relationship with him/her.
(2) What is your present occupation and permanent address? (2) ____________________________________
(3) What is your approximate monthly income and what are the (3) ____________________________________
_______________________________________ _________________________________________________________
(Name of Unit Holder)
Consequently I have filled in the questionnaire form given below:
Questions
(b) Bank A/c_____________Value__________
sources?
(4) What property moveable or immoveable (4) (a) Shares_____________Value____________
(1) Are you related to the unitholder / claimant? (1) ____________________________________
Unit Certificate No._____________ of
Agent/Manager of a Public Sector Bank, State Co-operative Bank, Member of Parliament, Member of State Legislative
Assembly.
* (This form can be used both in cases of issue of duplicate unit certificate and also settlement of claim in respect of units
held by deceased unit holders, by striking out the inapplicable words.)
N.B. : This application should be witnessed by a Magistrate( stipendary or honorary), NotaryP ublic, Gazetted Officer of the
Central or State Government, an Officer of the Reserve Bank of India, Industrial Development Bank of India, Secretary/